"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

May 24, 2019

Health officials in five states have warned people believed to be infected with measles and planning to travel that they could prevent them from getting on planes.

All eight individuals agreed to cancel their flights after learning the officials could ask the federal government to place them on a Do Not Board List managed by the Centers for Disease Control and Prevention, said Martin Cetron, director of the agency’s Division of Global Migration and Quarantine, which tracks disease outbreaks.

“The deterrent effect is huge,” he said.

CDC officials said the agency had been contacted about the individuals by health officials in New York, California, Illinois, Oklahoma and Washington.

The government’s travel ban authority often gets little discussion “because it is a politically charged and politically visible request,” said Lawrence Gostin, a professor of global health policy at Georgetown University.

Though less restrictive than isolation or quarantine, the public health measure “is seen as a government using its power over the people and the states, which is kind of toxic in America right now,” said Gostin. “There is nothing unethical or wrong about it. It’s just plain common sense that if you have an actively infectious individual, they should not get on an airplane.”

Health officials emphasize that vaccination is the best and most effective way to protect against measles, and that the majority of people with infectious, communicable diseases, like measles, listen to doctors’ advice not to travel.

Officials in Rockland County, N.Y. and New York City, the epicenter of measles outbreaks since last fall, say they have advised several infected individuals against traveling.

Earlier this spring, Rockland health officials, who have had 238 measles cases since last October, consulted with CDC about placing two infectious individuals on the list to prevent them from flying to Israel for the Passover holiday, a county spokesman said.

“It served as an effective deterrent,” said spokesman John Lyon. “They did not travel."

May 17, 2019

The Centre for Health Protection (CHP) of the Department of Health (DH) said today (May 17) that no additional case of measles infection had been recorded as at 4pm today and announced that the outbreak of measles infection at Hong Kong International Airport earlier has concluded.

A spokesman for the CHP said, "A total of 73 cases of measles infection were recorded so far this year, among them 29 cases were associated with the outbreak among airport workers. The incubation period of measles can last up to 21 days. Among the airport-associated cases, the date the patients last visited the airport during the communicable period was April 5. No new associated cases have been recorded in two incubation periods which ended today. We consider that the outbreak of measles infection at the airport has ended."

Regarding measles control measures implemented at the airport, a total of 23 persons had received measles vaccination at the airport vaccination station as at 6pm today, bringing the cumulative number of vaccinations given to 8 501 since March 22. The airport vaccination station will cease operation from tomorrow (May 18).

As for the blood test service, the DH earlier provided the measles serology test service to airport staff. A cumulative total of 777 blood samples have been collected. For the pilot service to provide measles serology testing for Filipino foreign domestic helpers working in Hong Kong, a total of 146 blood samples have been collected to date. Participants are notified individually of the serology results.

Measles elimination in Europe is in crisis. More than 80 000 confirmed cases were reported in 2018 in the 53 countries in the WHO European Region, the highest figure for 20 years. 14 countries in the region reported more than 500 confirmed cases, including four countries that were previously deemed to have eliminated measles (Greece, Albania, Israel, and the UK), meaning interrupted transmission for 3 years. New strategies are urgently needed to put measles elimination in Europe back on track.

In theory, controlling measles should be straightforward. Two doses of the measles, mumps, and rubella (MMR) vaccine provide highly efficacious protection that is long lasting. Yet, in practice, achieving elimination has proven challenging. One of the most contagious diseases, measles can strike susceptible pockets even if vaccination coverage on a national level is high.

Although asserting elimination status for individual nations might serve as a motivational tool, countries can experience large outbreaks even after several years of interrupted transmission. Countries such as Greece, Germany, and Kyrgyzstan reported consistently high MMR uptake over the past decade but are still experiencing outbreaks. Moreover, outbreaks do not occur in isolation: they traverse country borders, sometimes lasting years, and affecting different countries at different times.

In light of these issues, there is a need to link efforts across the continent. The Pan American Health Organization4 interrupted measles transmission in the early 2000s through combined strategies, including high routine immunisation, catch-up campaigns during periods of low transmission, and follow-up campaigns ensuring high levels of immunity at the age of school entry, all applied uniformly across the Americas.

Applying a similar joined-up approach in Europe would serve the dual purpose of increasing immunity in the general population while reducing the chance of imported cases reaching susceptible pockets.

Epidemiological investigation would also benefit from combined efforts. Linking genetic and case data to better understand chains of transmission has proven successful for other diseases and might reveal the interconnectivity of measles across Europe. Subnational seroprevalence studies could be used to better identify pockets of susceptibles. Improved vaccine supply, advocacy, and communication to population groups found to be most at risk could help increase immunity to the levels required.

Such efforts would come at a fraction of the cost of responding to outbreaks. The Americas have shown that elimination of measles is feasible through a combination of political willpower, targeted interventions, and concerted effort. If Europe can sustain a similar approach, it might still follow suit.

On October 1, 2018, the Rockland County (New York) Department of Health (RCDOH) alerted the New York State Department of Health (NYSDOH) of an unvaccinated teenaged traveler with diagnosed measles. During the next 17 days, RCDOH learned of an additional six unvaccinated travelers with measles.

On October 24, 2018, the Ocean County (New Jersey) Health Department alerted the New Jersey Department of Health (NJDOH) of a case of measles in an international traveler, with rash onset October 17. The unvaccinated travelers reported recent travel in Israel, where an outbreak of approximately 3,150 cases of measles is ongoing.

Investigations during October 1, 2018–April 30, 2019, identified 242 laboratory-confirmed and epidemiologically linked measles cases in New York, excluding New York City, and during October 17, 2018–November 30, 2018, identified 33 in New Jersey (Figure). The cases of measles were primarily in members of orthodox Jewish communities.

New York

The 242 cases in New York (excluding New York City) included 206 in Rockland County and 36 in nearby counties. Most patients resided in orthodox Jewish neighborhoods with low school immunization rates. The median patient age was 5 years (range = 0 days* to 63 years). The 2017–2018 New York State School Immunization Survey measles vaccination rate for students in prekindergarten through grade 12 was 98%; however, documented measles vaccination coverage in schools in the outbreak area was only 77%.

To prevent disease spread in schools, Rockland County and neighboring Orange County have excluded unvaccinated students from school for 21 days after a measles exposure. To further control spread after school exposures, in areas of Rockland County with measles cases, exclusions from school were expanded to include all nonimmune students at schools that had measles immunity rates of <95% as documented by 2 valid doses of measles-mumps-rubella vaccine (MMR) or serologic evidence of immunity.

To provide opportunities for vaccination, approximately 20 community vaccination events open to all ages were held in Rockland County and two in Orange County.

During October 1, 2018–April 30, 2019, Rockland County administered 19,661 MMR doses. NYSDOH, RCDOH, and private medical providers held nine informational events and distributed educational materials focused on measles prevention to 45,000 homes. A culturally appropriate and detailed vaccine education book was distributed to 15,000 Rockland County and 10,000 Orange County homes and medical providers.

Orthodox Jewish leaders were engaged in the outbreak response, with rabbinical leaders supporting vaccination efforts and community groups advocating for vaccination.

As of April 30, 2019, transmission was ongoing. This has been the largest measles outbreak in New York (outside New York City) since 1992 and, at 7 months, the longest documented outbreak in the United States since endemic measles was eliminated in 2000.

New Jersey

During October 17–November 30, 2018, 33 measles cases were confirmed in New Jersey, primarily in members of the orthodox Jewish community in Ocean County. The median patient age was 10 years (range = 6 months–59 years). In Ocean County, unvaccinated students were excluded from school for 21 days after a measles exposure. Some private schools excluded unvaccinated students for the duration of the New Jersey outbreak. NJDOH worked with local health officials and providers to facilitate delivery of >12,500 outbreak response doses of MMR vaccine to Ocean County medical providers. This outbreak was declared over on January 16, 2019.

A second outbreak occurred in the same community in March 2019, with no identified connection to the first outbreak.

In the New York outbreak, low community vaccination rates facilitated widespread measles transmission after introduction of imported measles in unvaccinated travelers.

Educational efforts regarding risks associated with undervaccination should be increased in communities with low vaccination rates. Health departments and clinicians should be aware of multiple ongoing measles outbreaks globally, and travelers should have evidence of measles immunity.

All U.S. communities should maintain ≥95% levels of age-appropriate vaccination coverage with 2 doses of MMR vaccine to ensure herd immunity (3).

MONSEY, N.Y. — An ultra-Orthodox rabbi falsely described the measles outbreak among Jews as part of an elaborate plan concocted by Mayor Bill de Blasio of New York to deflect attention from “more serious” diseases brought by Central American migrants.

A pediatrician questioned whether Jews were being intentionally given “bad lots” of vaccines that ended up giving children a new strain of the virus. And Andrew Wakefield, the British doctor whose study linking measles vaccines with autism was widely discredited and condemned, appeared via Skype to offer an almost apocalyptic vision of a world in which vaccines were giving rise to deadlier immunization-resistant diseases.

“We Hasidim have been chosen as the target,” said the rabbi, Hillel Handler. “The campaign against us has been successful.”

Since the measles outbreak began last fall, the health authorities have embarked on a sweeping and exhaustive campaign, repeatedly urging people to get vaccinated and fighting the spread of misinformation. They have made special efforts in the ultra-Orthodox communities of Brooklyn and Rockland County, N.Y., where the disease has been spreading most quickly.

But the rally on Monday in Monsey, a Rockland County town about 30 miles northwest of New York City, vividly illustrated how the anti-vaccine fervor is not only enduring, but may be growing: Hundreds of ultra-Orthodox Jews packed a ballroom for a “vaccine symposium” with leaders of the anti-vaccination movement.

Organized by a Monsey-based Jewish group, the event also showed how the movement was gaining ground: Greg Mitchell, a Washington-based lobbyist who represents the Church of Scientology, attended the meeting and addressed the crowd, offering to be their “voice in the public-policy game.”

The gathering was denounced by local elected officials, health authorities and some ultra-Orthodox rabbis, who said the speakers were spreading propaganda that could cause the outbreak to deepen, risking the health of countless people.

The Centre for Health Protection (CHP) of the Department of Health (DH) is today (May 14) investigating two cases of measles infection.

Both cases involve workers at a shop in Tsim Sha Tsui with an outbreak of measles infection announced yesterday. For the first case, a 27-year-old woman with good past health has developed fever since May 10 and rash since May 13. She attended the Accident and Emergency Department at Kwong Wah Hospital (KWH) on May 13. A laboratory test of her respiratory specimen was positive for the measles virus. She has been in a stable condition and reported to have received measles vaccination. She had no travel history during the incubation period and communicable period.

The second case involves a 31-year-old man with good past health who developed rash since May 12. He attended the Accident and Emergency Department at KWH on May 13. A laboratory test of his respiratory specimen was positive for the measles virus. He has been in a stable condition and reported to have received measles vaccination. He had no travel history during the incubation period and communicable period.

According to both patients, they did not have contact with measles patients during the incubation period. Their home contacts have remained asymptomatic so far and have been put under medical surveillance.

Upon notification of the cases, the CHP immediately commenced epidemiological investigations and conducted relevant contact tracing. Investigations are ongoing. The public places the patients visited during the communicable period are listed in the appendix.

For the outbreak of measles infection at the shop in Tsim Sha Tsui, measles mop-up vaccination for workers of the shop has concluded and a total of 143 vaccinations had been given.

Three workers at a Gucci outlet in Hong Kong have fallen ill with measles in the past week, according to health officials.

The outbreak of the highly infectious disease at the luxury fashion shop in the Harbour City shopping centre in Tsim Sha Tsui caused the store to close early on Monday, while the mall’s management deployed cleaners for disinfection.

The growing number of cases recorded in Hong Kong this year has put local health authorities on high alert.

The first Gucci worker affected, a 30-year-old salesman, came down with a fever last Tuesday when he flew to Tokyo on HK Express flight UO848. He developed a rash three days later.

The man returned to the city on the budget airline’s flight UO33 on Saturday and attended the emergency unit at Kwong Wah Hospital in Yau Ma Tei. The patient was admitted to Princess Margaret Hospital in Kwai Chung the following day.

His respiratory specimen tested positive for the measles virus. The man, who had previously received the measles vaccine and had a good health record, was listed in stable condition, the Centre for Health Protection said on Monday night.

An investigation showed he had not been overseas during the incubation period, which lasts from seven to 21 days before the onset of symptoms.

The second case involved a 25-year-old saleswoman. She developed a fever and rash on Saturday. She also sought treatment at Kwong Wah Hospital before being admitted to Tuen Mun Hospital on Monday.

The woman, who had also been vaccinated, had no travel history during the incubation period but had been to Shenzhen during the communicable period.

The third employee, another 25-year-old saleswoman, developed symptoms from Wednesday. She was admitted to Tseung Kwan O Hospital on Saturday and her condition was stable.

She had been to Macau during the incubation period.

The three patients, all locals, brought the number of measles cases in the city this year to 73 including 29 associated with an outbreak among workers at the city’s international airport. The number of cases last year was 15.

A centre spokesman said the three did not have contact with measles patients during the incubation period. Their home contacts remained asymptomatic. None had worked at other Gucci shops.

Health authorities gave a measles “mop-up” vaccination to 96 of the about 190 workers in the shop on Monday and would continue the operation on Tuesday.

May 12, 2019

Authorities in the Caribbean island of Curacao have announced that 17 crew members and 11 passengers must stay on board a ship owned by the Church of Scientology that is under quarantine following a confirmed case of measles.

Dr Izzy Gerstenbluth said the group was required to stay on the 440-feet Freewinds ship until 13 May because they were still at risk of contracting measles after a female crew member came down with the virus.

He said the remaining 318 crew and passengers were free to leave. “They are not a threat to anyone any more, and they cannot become sick any more.”

According to the church’s website, the ship is the home of “a religious retreat ministering the most advanced level of spiritual counselling”.

The ship was previously quarantined in St Lucia and arrived in its home port of Curacao a week ago. Authorities then took 277 blood samples from those who did not have proof of vaccination and sent the samples to the Netherlands.

Chicago, Los Angeles and Miami are the cities most likely to see the next measles outbreaks, according to an unusual new study.

Researchers at the University of Texas at Austin and Johns Hopkins University mapped the 25 American counties most at risk of measles because of their vaccine-exemption rates and proximity to airports.

A similar map published last year proved surprisingly accurate at forecasting many of this year’s cases. But both groups of scientists failed to predict the measles outbreak that began in Brooklyn, currently the nation’s largest.

These prediction models need refining, one expert noted, and the Centers for Disease Control and Prevention should make it a priority in order to get ahead of measles cases.

The study, published this week in The Lancet Infectious Diseases, found that Cook County, which includes Chicago, was likeliest to experience a measles outbreak. Los Angeles and Miami-Dade counties were next, followed by New York’s Queens County and the counties that include the cities of Seattle, Phoenix, Fort Lauderdale, Las Vegas, Houston and Honolulu.

To assess risk, the researchers looked at how many children in counties across the country had nonmedical vaccination exemptions — which include “religious,” “philosophical” or “personal belief” exemptions, depending on state law.

The team then focused on counties with international airports, because every American outbreak since 2000 has begun with a case imported from overseas.

They gave greater weight to airports with many passengers arriving from countries with thousands of measles cases, including India, China, Mexico, Japan, Ukraine, the Philippines and Thailand.

However, both studies failed to foresee what is now the country’s largest outbreak — the one among Orthodox Jews in the Williamsburg neighborhood of New York — which is in Brooklyn, not Queens.

(The Lancet authors said their forecasts were correct about two-thirds of the time, as long as counties “spatially adjacent” to the ones they saw as potential hot spots were included.)

In September last year, the virus spread from Ukraine to Orthodox Jewish communities in Israel. One month later, Orthodox Jews from New York carried measles almost simultaneously to Brooklyn and to suburban Rockland County, N.Y. The outbreak spread from New York to Orthodox communities in Michigan.

“What we did not calculate at all was that it would come from Israel,” said Sahotra Sarkar, a professor of philosophy and integrative biology at the University of Texas at Austin and a co-author of the new study.

A similar study published last June in PLOS Medicine ranked the risk of measles outbreaks in 18 states with philosophical or personal belief exemptions to vaccination. The research was prescient: almost half the “hotspot” metropolitan areas the scientists noted — particularly Washington State, Texas and Michigan — saw outbreaks this year.

“In the major leagues, that’s an all-star batting average,” said Dr. Peter J. Hotez, a director of the Texas Children’s Hospital Center for Vaccine Development and a co-author of the PLOS Medicine study.

Dr. Hotez and his colleagues did not look at New York State because it does not have “philosophical” exemptions to vaccination, although the state permits religious ones — a loophole that the legislature is considering eliminating.

“What I never expected was an outbreak in Jewish communities,” Dr. Hotez joked. “In my book, Jews make the vaccines.” (Dr. Hotez, who is Jewish and researches vaccines against tropical diseases, cited such pioneers as Albert Sabin, Jonas Salk, Stanley Plotkin and Rachel Schneerson.)